Aunt's nursing home hinders exit

Lisa Zamosky, Special to the Los Angeles Times

My aunt is in a nursing home. They tell us she isn't allowed to leave unless she gets the doctor's permission. If she does, she has to sign a statement saying she doesn't hold them liable and will lose all her healthcare coverage. She is on Medicare. Can you help?

For starters, no doctor or any other healthcare provider has the authority to strip you of your health insurance benefits, including Medicare, the federal program for senior citizens.

There are requirements that must be met in order for Medicare to cover some of the cost of your aunt's current stay in the skilled nursing facility, or SNF. However, it's unlikely that the care she's already received from the home would be denied because she left against the doctor's orders.

What determines coverage is that there was a qualifying three-day hospital stay before entering the SNF, that your aunt has Medicare Part A with days left in the benefit period and that the services she received in the SNF were ordered by her doctor and are related to the treatment of her diagnosed condition. For more information about benefits, visit the Medicare Rights Center at medicareinteractive.org.

Also inaccurate is the nursing home staff's assertion that your aunt is not allowed to leave, says Eric Carlson, directing attorney with the Los Angeles office of the National Senior Citizens Law Center. "The person isn't incarcerated, and doctors are professionals hired to give advice, not to force people to do things against their will," he says.

If someone chooses to leave a nursing home against a doctor's advice, the decision simply has to be documented. "Often it's the kind of thing that can be noted on the medical chart," Carlson says.

With regard to signing a document related to liability, steer clear of anything stating that the doctors or facility are off the hook for any wrongdoing. "Healthcare people can't [legally] absolve themselves from their own negligence," Carlson says.

It's possible that the staff at the nursing home have misunderstood what they've been told about discharge procedures and/or Medicare benefits, which are quite complicated. This is a common problem, according to Carlson.

Understanding your rights and communicating them clearly to the staff often is enough to rectify the situation. A good place to start is the National Senior Citizens Law Center's website (www.nsclc.org), which offers a free consumer guide called "20 Common Nursing Home Problems and How to Resolve Them."

If you continue to face trouble, however, there are places to turn for help.

The Office of the Medicare Ombudsman handles complaints. To find a representative in your state, visit the National Long-Term Care Ombudsman Resource Center at http://www.ltcombudsman.org/ombudsman.

In California, an ombudsman can be located by county on the California Department of Aging website, http://www.aging.ca.gov. Click on "Other Service Providers" and navigate your way to the Long-term Care Ombudsman Program, which has a link to local county program coordinators.

If you have concerns about the quality of care being delivered at a specific nursing facility, you can file a complaint with your state's Department of Public Health.

To report abuse, go to the National Center on Elder Abuse website at http://www.ncea.aoa.gov, click on "Nursing Home Abuse," then "Where to Report" to find hotlines in your state.

If your circumstance requires you to work with a lawyer, you can find one at the National Academy of Elder Law Attorneys (www.naela.org) or the California Advocates for Nursing Home Reform (www.canhr.org).

Few people know about health savings accounts and the insurance plans that go along with them. I think they are the answer to many people's health insurance dilemmas.

Health savings accounts, or HSAs, can be a good value for some people. They are investment accounts — like a 401(k) retirement plan or a 529 college savings plan — that can be opened by anyone enrolled in a qualified health insurance plan that has a deductible of at least $1,200 for an individual and $2,400 for a family.

These accounts allow you to set aside money, tax free, to spend on a wide range of medical expenses, including doctor visits, prescription drugs, eye glasses, hospital care and dental care. To see a list of qualified medical expenses, visit www.irs.gov/publications and select Publication 502.

According to Mike Thompson, a principal with PricewaterhouseCoopers who specializes in healthcare benefits, HSAs offer favorable tax terms because the money you deposit goes in tax-free, accumulates tax-free and can be withdrawn tax-free as long as the money is spent on qualified healthcare costs.

This year, a single person can contribute a maximum of $3,050 to his or her account, and families can put away as much as $6,150. If you're 55 or older, you can kick in an additional $1,000 through what's called a "catch-up" contribution.

If you don't use all the money you've deposited in a given year, it carries over into the next year.

Just be sure to check for hidden costs. "It's important for people to do their homework," says Carrie McLean, consumer specialist with online insurance brokerage eHealthInsurance.com. Costs to set up the account, monthly fees and, in some cases, charges associated with the checks and/or debit cards used to spend money from the HSA account may apply.

Despite the tax benefits of HSAs and the fact that the monthly premiums for their accompanying health plans tend to be less expensive than other insurance plans, they don't make sense for everyone. Critics have argued that they primarily benefit young and healthy people who don't use a lot of medical services and high-income individuals who are more likely to benefit from the investment tax breaks.

You need to be comfortable shelling out 100% of your medical costs until you've met your high deductible. For people who aren't in a position to sock away money in an HSA, this may not be a good option, McLean says.

To determine if an HSA plus a high-deductible insurance plan is right for you, try an online calculator from an insurance company or employer who offers these plans.

"They'll help you do the math to figure out what's in your best interest," Thompson says of the calculators. Once you've crunched the numbers, however, Thompson says it's important to consider the emotional side of the decision.

"Be honest with yourself about how much money you're comfortable paying upfront before insurance benefits kick in," he says.

Zamosky has been writing about how to access and pay for healthcare for more than 10 years. She may answer your question in a future column but regrets that she cannot personally respond to all emails.